Healthcare Provider Details

I. General information

NPI: 1689500258
Provider Name (Legal Business Name): LORD MINTAH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3249 KINGSBRIDGE AVE # 10463
BRONX NY
10463-5514
US

IV. Provider business mailing address

20 WILLOW PL APT E1
YONKERS NY
10701-2471
US

V. Phone/Fax

Practice location:
  • Phone: 917-352-3625
  • Fax:
Mailing address:
  • Phone: 914-483-0349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: